Secondary Survey

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In the secondary survey, document a history from the patient, the patient's relatives, emergency department personnel, or bystanders. The secondary survey is a systematic method for determining whether other conditions or injuries are present and necessitate attention.

This survey consists of a rapid interview, a check of the vital signs, and a focused physical examination. The mnemonic AMPLE can be helpful in gathering pertinent information:

A: allergies

M: medications currently being taken

P: past medical history

L: last meal

E: events preceding the medical event

A critical piece of information in dealing with a trauma patient is the mechanism of injury. Did the patient sustain blunt trauma, or was a weapon used to cause a penetrating injury? In the case of a vehicular accident, ascertain whether the patient was ejected from the car or was wearing a seat belt and whether there were other injuries or fatalities in the accident. In addition, trauma victims must have all their bones and joints—including the rib cage, pelvis, facial bones, and skull—palpated and gently compressed to determine whether there is a fracture step-off or crepitation;also check for stability of structure and for function. A screening neurologic examination is necessary to determine whether there are focal cranial nerve, motor, or sensory findings. Most patients with multisystem trauma require a rectal examination to determine the presence of blood, tenderness, or upward displacement of the prostate. The latter is a sign of urethral injury.

If alert, an injured patient can direct you to the appropriate body areas to be evaluated during the physical examination. The assessment of the patient involves examination of three main regions: the head and neck, the torso, and the extremities. Can the patient move the neck? Ask the patient to move the neck slowly. Can the shoulders be moved? Ask the patient to take a deep breath and then blow it out. Does this elicit any pain? Is the patient able to move the fingers? Can the arms be bent? Can the patient move the toes? ankles? Can the patient bend the legs? If the patient can move all extremities without experiencing pain, help the patient up to a sitting position slowly. If the patient cannot move a body part or can do so only with pain, reassess the airway, breathing, and circulation, and get immediate assistance. Continue to observe the patient's level of consciousness, breathing, and skin color.

Head and Neck

Look at the victim's face. Evaluate skin color and temperature. Is there evidence of raccoon eyes or Battle's sign? A patient with raccoon eyes is shown in Figure 10-28. Periorbital ecchymoses, or raccoon eyes, are seen 6 to 12 hours after a fracture of the base of the skull. Battle's sign is ecchymosis behind the ear caused by basilar skull or temporal bone fractures; this sign may take 24 to 36 hours to develop. Palpate the head.

Examine the eyes for pupillary size and responsiveness to light. Are the pupils equal? Are the pupils pinpoint? Is there a unilateral dilated pupil? Are the pupils fixed? Table 26-1 reviews the eye signs in a comatose patient.

Is there a discharge from the ears, nose, or mouth?

Inspect the neck. Is the trachea deviated? Suspect a chest injury, such as a tension pneumothorax, if the trachea is not midline. Palpate the neck for crepitus, which is indicative of air under the skin from rupture of the lung.

Abdomen

Inspect the abdomen. Is abdominal distention present? Is there evidence of blunt abdominal trauma, such as an ecchymosis, an abrasion, or an abdominal wound? Cullen's sign is a bluish discoloration around the umbilicus indicative of intra-abdominal bleeding or trauma. Grey Turner's sign is ecchymotic discoloration around the flanks, which is suggestive of retroperito-neal bleeding. Swelling or ecchymosis often occurs late; therefore, its presence is extremely important.

Gently palpate the abdomen, noting the presence of tenderness. If the patient is a woman of childbearing age, always consider the possibility that she may be pregnant. Inspect the anus and the perineum. Inspect the urethral meatus for blood.

Table 26-1 Eye Signs in a Comatose Patient Eye Sign

Pupils reactive, eyes directed straight ahead,

Toxic/metabolic cause

Possible Causes normal oculocephalic reflex (OCR){ Pinpoint pupils

Narcotic poisoning (OCR intact) Pontine or cerebellar hemorrhage (OCR

absent) Thalamic hemorrhage Miotic eye drops

Disconjugate deviation of eyes Conjugate lateral deviation of eyes

Structural brain-stem lesion

Ipsilateral pontine infarction Contralateral frontal hemispheric infarction

Unilateral dilated, fixed pupil with no consensual responses

Supratentorial mass lesion Impending brain herniation Posterior communicating aneurysm

Bilateral midposition pupils, fixed pupils

Midbrain lesion Impending brain herniation

Raccoon eyes (periorbital ecchymoses),

Fracture of the base of the skull

Battle sign

*Eye signs are difficult to evaluate in patients with artificial lenses, prosthetic eyes, contact lenses, or cataracts or after cataract surgery.

^"Doll's eyes'': Rotate the head quickly but gently from side to side. In an unconscious patient with an intact brain stem, the eyes move conjugately in a direction opposite the head turning.

Perform a rectal examination to assess anal sphincter tone, to determine whether blood is present, and to verify that the prostate is in its normal position.

Use the heels of your hands to apply gentle downward pressure on the anterior superior iliac spine and on the symphysis pubis. Is tenderness present? If so, there may be a fracture of the pelvic ring.

Extremities

Inspect and palpate all extremities for evidence of injury. Try to determine whether the patient can move all extremities. Palpate all peripheral pulses.

Inspect the back, looking for obvious signs of injury. This can be done by gently insinuating your hands beneath the back and neck without moving the patient. If this cannot be done, the patient should be gently ''log-rolled'' onto the side. To do this, you need at least four assistants: one to control the head and neck, two to roll the patient onto the side, and one to cautiously move the lower extremities. Figure 26-3 shows this log-roll procedure.

Vital Signs

Reassess vital signs.

Documenting the history from an acutely ill patient conforms closely to documentation of the standard history, but it is abbreviated to allow rapid diagnostic and management decisions to be made. The physical examination of an acutely ill nontrauma patient includes cardiopulmonary and abdominal examinations and evaluation of the peripheral pulses.

Pelvis

Back

Medical Log Rolling

Figure 26-3 Log-roll procedure. A, Positioning for log-rolling. (1) Apply a cervical spine immobilization device and place the patient's arms at the side. Note that one emergency management technician (EMT) maintains cervical immobilization manually throughout this procedure. (2) Three EMTs can be positioned at the side of the patient at the level of the chest, hips, and lower extremities while the long spine board is positioned on one side of the patient. (3) Check the patient's arm on the side of the EMTs for injury before log-rolling the patient, and then align the lower extremities. Note: The EMT at the lower extremities holds the patient's lower leg and thigh region; the EMT at the hips holds the patient's lower legs and places the other hand on top of the patient's buttocks; and the EMT at the chest holds the patient's arms against the body and at the level of the lower buttocks. B, Log-rolling the patient.

(4) On command from the EMT at the head, all EMTs rotate the patient toward themselves, keeping the body in alignment.

(5) The EMTs then reach across with one hand and pull the board beneath the patient's arm. (6) On command from the EMT at the head, they gently roll the patient onto the board and then roll the board to the ground. (7) Strap the patient's torso and extremities securely to the board, and immobilize the head.

Figure 26-3 Log-roll procedure. A, Positioning for log-rolling. (1) Apply a cervical spine immobilization device and place the patient's arms at the side. Note that one emergency management technician (EMT) maintains cervical immobilization manually throughout this procedure. (2) Three EMTs can be positioned at the side of the patient at the level of the chest, hips, and lower extremities while the long spine board is positioned on one side of the patient. (3) Check the patient's arm on the side of the EMTs for injury before log-rolling the patient, and then align the lower extremities. Note: The EMT at the lower extremities holds the patient's lower leg and thigh region; the EMT at the hips holds the patient's lower legs and places the other hand on top of the patient's buttocks; and the EMT at the chest holds the patient's arms against the body and at the level of the lower buttocks. B, Log-rolling the patient.

(4) On command from the EMT at the head, all EMTs rotate the patient toward themselves, keeping the body in alignment.

(5) The EMTs then reach across with one hand and pull the board beneath the patient's arm. (6) On command from the EMT at the head, they gently roll the patient onto the board and then roll the board to the ground. (7) Strap the patient's torso and extremities securely to the board, and immobilize the head.

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